22 October 2020

Before HM Senior Coroner Alison Mutch OBE
Manchester South Coroner’s Court
12 – 22 October 2020
The inquest into the death of four month old Alfie Gildea, who was unlawfully killed by his father, concluded today with a detailed conclusion identifying a series of failings which contributed to his death. The coroner found that Greater Manchester Police (GMP), Children’s Services and the Health Visiting team all failed to assess the risk to Alfie or recognise coercive and controlling behaviour by Alfie’s father. It was further concluded that the GMP failed on multiple occasions to assess Alfie’s father as a serious and serial abuse perpetrator, recognise he was in a controlling relationship with Alfie’s mother and ensure disclosure under Clare’s Law*.
Alfie died on the 14 September 2018, two days after his mother found him unresponsive. Samuel Gildea, Alfie’s father, later pleaded guilty to manslaughter after admitting an 'act of deliberate and unlawful violence which involved rigorous and violent shaking,' as well as coercive and controlling behaviour towards Alfie’s mother, Caitlin. The medical cause of Alfie’s death was a head injury. Samuel had been left to care for Alfie for less than 30 minutes whilst Caitlin attended a doctor’s appointment. He is now serving a sentence of 19 years’ imprisonment.
Samuel had 20 previous convictions and was last imprisoned in 2010. The inquest heard that Caitlin, who met Samuel in 2016, knew that he had been in prison for burglary. She also had concerns about his mental ill health. From July 2018 onwards, Caitlin was asked on various occasions by police officers if she knew about his past, and Caitlin confirmed that she did. However, nobody checked with her the extent of her knowledge. She was not aware of his past involving domestic violence, including six separate occasions of abuse involving three previous partners. Caitlin told the inquest that had she known, she would have never allowed him near her children.
When Alfie was two months old, Samuel physically assaulted Caitlin by dragging her by her hair from the garden to the house. When speaking to the police, Caitlin disclosed that Samuel had attempted to strangle her two weeks previously. Despite the severity of the threats and violence of these incidents, GMP categorised the situation as of medium risk. The Multi Agency Referral and Assessment Team (MARAT) accepted at the inquest that they should have instituted a Child and Family Assessment. Children’s Social Care and Health Visitors were both informed in part of what had happened but did not enquire in depth, which the coroner found to be a failing which probably contributed to Alfie’s death. Nobody discussed the situation with Caitlin face to face in July or August 2018, with all interaction with services taking place over the telephone.
Caitlin did not feel protected and continued to feel terrified of Samuel. According to GMP’s domestic abuse policy, Samuel should have been recognised as a serial perpetrator because of his history.
Caitlin McMichael, Alfie’s mother said: “Alfie was such a happy and contented baby with the most heart-warming smile. I am devastated that nothing can bring Alfie back. I wish that someone had taken the time to speak with me face to face, rather than receiving numerous impersonal phone calls from different services. The police who investigated his death did so with enormous dedication. I just wish that the police officers who came to me before had interrogated their records in the same way. Had such critical information regarding Samuel’s past been shared, Alfie could still be alive today.”

Selen Cavcav, Senior Caseworker at INQUEST said: “What has been exposed in this inquest is not an isolated problem around individuals not doing their jobs properly, but part of a systemic issue around police’s understanding of domestic violence and the culture surrounding this. With a disturbing surge in domestic abuse across the country throughout the duration of the COVID-19 pandemic, such inadequate systems must be urgently addressed to prevent further harm.”

Ruth Bundey of Harrison Bundey Solicitors, who represents Caitlin, said: It is unacceptable that it took Alfie’s death before the information of Samuels previous domestic abuse history was scrutinised by Greater Manchester Police. Crucial information was available to show that Caitlin was in a controlling and coercive relationship. This was not recognised or contextualised by GMP, Children's Services or the Health Visitors Team, and had a proper risk assessment ensued, Alfie‘s death could probably have been prevented."



For further information please contact Sarah at INQUEST [email protected]

INQUEST has been working with the family of Alfie Gildea since November 2019. The family is represented by INQUEST Lawyers Group member Ruth Bundey of Harrison Bundey Solicitors. The family are supported by INQUEST caseworker Selen Cavcav.

*The Domestic Violence Disclosure Scheme (DVDS, also known as “Clare’s Law”) enables the police to disclose information to a victim or potential victim of domestic abuse about their partner’s or ex-partner’s previous abusive or violent offending. More information
Alex Malcolm, 5, was killed by a man in November 2016. The former partner of his mother was under supervision of probation service following a series of convictions for violent behaviour. Despite having spoken to the relevant probation officer, Alex’s mother was never made aware of her former partner’s history and the risks for which he was being monitored. See the closing media release.